Does access to acute intensive trauma rehabilitation (AITR) programs affect the disposition of brain injury patients?

Early incorporation of rehabilitation services for severe traumatic brain injury (TBI) patients is expected to improve outcomes and quality of life. This study aimed to compare the outcomes regarding the discharge destination and length of hospital stay of selected TBI patients before and after launching an acute intensive trauma rehabilitation (AITR) program at King Saud Medical City. It was a retrospective observational before-and-after study of TBI patients who were selected and received AITR between December 2018 and December 2019. Participants' demographics, mechanisms of injury, baseline characteristics, and outcomes were compared with TBI patients who were selected for rehabilitation care in the pre-AITR period between August 2017 and November 2018. A total of 108 and 111 patients were managed before and after the introduction of the AITR program, respectively. In the pre-AITR period, 63 (58.3%) patients were discharged home, compared to 87 (78.4%) patients after AITR (p = 0.001, chi-squared 10.2). The pre-AITR group's time to discharge from hospital was 52.4 (SD 30.4) days, which improved to 38.7 (SD 23.2) days in the AITR (p < 0.001; 95% CI 6.6-20.9) group. The early integration of AITR significantly reduced the percentage of patients referred to another rehabilitation or long-term facility. We also emphasize the importance of physical medicine and rehabilitation (PM&R) specialists as the coordinators of structured, comprehensive, and holistic rehabilitation programs delivered by the multi-professional team working in an interdisciplinary way. The leadership and coordination of the PM&R physicians are likely to be effective, especially for those with severe disabilities after brain injury.

Introduction

Trauma is a significant public health burden in Saudi Arabia due to the high road traffic crash rate [1]. It has severe, devastating, and often life-threatening consequences. Care for the injured after a crash is exceptionally time sensitive; delays in any stage can make a difference in outcomes. Survivors of significant trauma may experience severe functional impairment and reduced quality of life [2]. Severe injuries are often associated with motor, sensory, and autonomic impairments, including loss of bladder control and bowel evacuation. These contribute to significant morbidity and impact an individual’s ability to move about their home and community and bathe and dress independently [3-5].

Advanced rehabilitation services have become critical for enhancing a patient’s functional health status following significant trauma. Early intensive rehabilitation significantly reduces dependency, lessening the need for ongoing community care [6]. The World Health Organization recommends that rehabilitation be available and accessible to anyone who experiences a severe traumatic injury [7]. Acute intensive trauma rehabilitation (AITR) programs following traumatic injuries have also improved functional recovery. However, access is often limited and not available at all hospitals [8]. For example, only 1.5% of patients in Beijing, China, receive this service compared with 50% to 58% in Ontario, Canada [9, 10].

In Saudi Arabia, King Fahad Medical City (KFMC) rehabilitation hospital is the only hospital under the Ministry of Health providing holistic rehabilitation services in the region since 2004 [11]. Due to the limited number of inpatient beds and a huge burden of rehabilitation candidates, the waiting time for patients’ acceptance is 6–12 months. Another private rehabilitation center is also available that has limited access due to eligibility and insurance coverage. On the other hand, King Saud Medical City (KSMC) in Riyadh is a major trauma center in the region. It receives the most severely injured polytrauma patients from all over the country. A dedicated trauma unit has managed all polytrauma patients since 2016.

KSMC lacked consultant physiatrists, and the physical medicine and rehabilitation (PM&R) department was severely understaffed for such a major hospital in the region until 2017. With only one PM&R registrar, the focus of services was on outpatient care. There were the physiotherapy, occupational therapy, speech-language pathology, and prosthesis and orthosis departments, which were all inadequately involved with patient care because there was no integration between services. Since the trauma unit’s inception in 2016, we have been trying to improve trauma care, especially chronic care, for severely injured brain trauma patients. Since then, we have undertaken different administrative measures, including recruiting PM&R professionals, increasing logistics, and collaborating with the KFMC rehabilitation center. As a part of that collaboration, one visiting consultant physiatrist from KFMC used to visit the KSMC trauma unit once a week to assess the chronic trauma patients and select rehabilitation candidates. He also provided expert opinion for interim hospital care before those patients were transferred to his rehabilitation center. The waiting time for the transfer was long. These chronic patients were receiving essential non-intensive hospital care—such as physiotherapy, occupational therapy, tracheostomy care, and speech-language therapy—in the trauma unit. It was causing bed occupation, increased length of hospital stay, and increased cost. Around this time, two more consultant physiatrists joined KSMC. Subsequently, an integrated multidisciplinary AITR program was implemented at KSMC in December 2018.

This study aimed to compare the outcomes regarding discharge destination and length of hospital stay of selected traumatic brain injury (TBI) patients before and after the launch of the multidisciplinary AITR program.

Materials and methods

Setting

KSMC is one of the largest hospitals in Saudi Arabia, with 1,400 inpatient beds. KSMC’s emergency department (ED) is the busiest in the kingdom [12]. Three physiatrists oversee the KSMC PM&R department. The department started the AITR program in coordination with physiotherapy, occupational therapy, speech-language pathology, prosthesis and orthosis, and the social work department in December 2018.

AITR

AITR is an acute in-hospital intensive rehabilitation program for a selected group of severely injured trauma patients who receive at least two to three sessions of different therapies—including physiotherapy, speech-language therapy, occupational therapy, and Botox therapy—for three to four hours each day with breaks in between, five days a week, as decided by the physiatrist [13].

The AITR program was created with specific clinical goals. The multidisciplinary team’s training was designed to help people regain function, acquire activities of daily living (ADL) independence, and reintegrate into their homes and communities. The program included physical and sensory-motor training from physiotherapy, functional re-training such as self-care and instrumental ADL from occupational therapy, and psycho-social re-training including social skills from speech therapy [13].

Assessment and selection of TBI patients for AITR

The PM&R department engages with trauma patients’ management at an early stage of their in-hospital courses. A consultant physiatrist does weekly rounds on trauma patients to assess needs and select candidates for AITR. When a patient has fully recovered from an acute head injury, has regained consciousness, and is able to participate in rehabilitation, the physiatrist sets up short-term integrated goals for the patients in collaboration with the treating trauma surgeon and other relevant departments (e.g., physiotherapy, occupational therapy, speech-language pathology, prosthesis and orthosis, and social work) in a multidisciplinary team meeting. Assessment is based on a favorable outcome regarding achievement of independence in daily activities after providing the service. The plans are then revised with patient progress. The persistent vegetative and worse-prognosis patients are recommended for nursing care only. After AITR, if a patient is improved with the achievement of independence in daily activities, they are discharged home with outpatient follow-up at our PM&R department as needed. If the patient needs further rehabilitation to achieve the goals, they are transferred to a long-term rehabilitation facility. The selection criteria or preconditions for AITR are described in Table 1.

Table 1

Patient selection criteria for AITR.

1. The patient must be medically stable. Medical stability refers to optimizing the patient’s physical condition, including diseases or dysfunction of the viscera (e.g., respiratory, cardiovascular, gastrointestinal, urologic, endocrine, and neurological disorders). Criteria: I. The patient must be afebrile for 48 hours, may have low-grade temperature if a source has been identified and a treatment plan is in place. II. The patient must not require suctioning more frequently than every four hours. III. The patient should have a stable cardiac rhythm. IV. The patient who requires oxygen must have adequate oxygen saturation on portable oxygen. V. The patient must be off from continuous positive airway pressure (CPAP), except for sleep apnea treatment. VI. If the patient has a chest tube, it must be stable to gravity for at least 48 hours. VII. The patient’s medical or surgical workup and treatment must be complete. VIII. If a patient has nutritional, pain, or wound issues, they must be manageable and not interfere with the therapies.

2. The patient must meet the criteria of at least two of the three (physiotherapy, occupational therapy, and speech-language therapy) major therapy areas.

3. The patient must have the endurance to tolerate at least three to four hours of therapy over the day.

Source: KSMC policy on Intensive Rehabilitation Joint Program, IPP-KSMC-015-V1

Design

This was a retrospective observational before-and-after study of TBI patients who were referred to PM&R and received AITR between December 01, 2018, and December 31, 2019. The TBI patients who died in the hospital, transferred to another hospital during acute care, or were discharged from the hospital after rapid and good recovery that did not require rehabilitation and remained persistent vegetative were excluded. The data were compared with the pre-integration of inpatient rehabilitation for TBI patients who were assessed and selected for rehabilitation care between August 01, 2017, and November 30, 2018.

Before discharge home, a patient had to be able to: (1) execute self-care activities such as feeding, grooming, dressing, and toileting; (2) move from bed to chair/wheelchair/shower chair independently; (3) securely handle household appliances; and (4) walk with or without support inside the ward [13]. These criteria remained the same in pre-AITR and AITR era.

Data collection

The data of selected TBI patients who were referred for possible rehabilitation care were collected from the PM&R department and trauma unit records. Then for these selected patients, the data of patient demographics, mechanism of injuries, baseline admission characteristics (on presentation to ED), length of stay, and discharge destination in terms of home or rehabilitation center were extracted from the KSMC trauma registry. Discharge destination and time to discharge from hospital were the primary outcome variables.

Statistical analysis

The data were analyzed using SPSS 25.0 (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.) and R (RStudio Team 2020). The data were subgrouped into the two periods before and after the implementation of AITR. Demographic, mechanism of injury, and baseline injury characteristics (on presentation to ED) were compared to assess equivalence between the two subgroups. The continuous and normally distributed data (e.g., age, respiratory rate, heart rate, systolic blood pressure, international normalized ratio, base excess, PH, abbreviated injury scale [AIS] head, and length of stay) were summarized using mean (standard deviation [SD]) and compared using Student’s t-test. Skewed and ordinal data (e.g., Glasgow Coma Scale) were summarized using the median (inter-quartile range [IQR]) and compared using the nonparametric Mann-Whitney U-test. Count data (e.g., male sex, mechanism, trauma team activation, blood transfusion in ED, injury-severity score, and discharge destination) were summarized using proportions and compared using the nonparametric chi-square test. A p-value of < 0.05 was considered significant.

Ethics statement

The study was approved by King Saud Medical City institutional review board (IRB) with a reference number of H1RI-03-Oct18-02. The IRB committee approved a waiver of the requirement to seek informed consent from the participants for a retrospective review of their data.

Results

A total of 5,933 trauma patients were included in the KSMC registry between August 2017 and December 2019. Of these, 3,419 (57.6%) patients were admitted pre-AITR era and 2,514 (42.4%) patients were admitted after the introduction of AITR. During the pre-AITR period, 2,021 (59.1%) patients sustained TBI, of which 118 (5.8%) died, 1,737 (86%) were discharged after rapid and good recovery that did not require rehabilitation, and 166 (8.2%) became chronic TBI patients (who required rehabilitation care or were persistent vegetative patients). Among the chronic TBI patients, 108 (65%) were selected for the rehabilitation care, and the remaining persistent vegetative patients were selected for nursing care. On the other hand, during the AITR era, 1,578 (62.8%) patients sustained TBI, of which 105 (6.7%) died, 1,315 (83.3%) were discharged after rapid and good recovery that did not require rehabilitation, and 158 (10%) became chronic TBI patients. Among the chronic TBI patients, 111 (70.3%) were selected for AITR, and the remaining persistent vegetative patients were selected for nursing care (Fig 1).

Fig 1

Sample selection.

In the combined group of chronic TBI patients selected for rehabilitation care (n = 219), the demographics were mainly young males (195, 89%) with a mean age of 28.2 (SD 14.2) years. The age distribution is presented in the violin plot (Fig 2).

Fig 2

Age distribution of patients.

The commonest mechanism of injury was motor vehicle crashes (192, 87.7%) followed by falls (22, 10%) and assaults (5, 2.3%). Eighty-four (38.4%) patients had trauma team activation (TTA) by the ED, and 27 (12.3%) patients received a blood transfusion in the ED. Ninety-three (42.5%) patients had an injury severity score (ISS) between 16 and 25, followed by 81 (37%) patients less than 16 and 45 (20.5%) patients above 26. The average length of ICU and hospital stay were 18 (SD 10.2) and 45.5 (SD 27.8) days, respectively.

The comparison of selected TBI patients’ demographics, mechanisms of injury, baseline (on presentation to ED) characteristics, and outcomes between pre-AITR and AITR are described below (Table 2). There was no significant difference in the AIS for the head between the groups (p = 0.437).

Table 2

Comparison of selected TBI patients’ demographics, mechanisms of injury, baseline (on presentation to ED) characteristics, and outcomes between pre-AITR and AITR.

Characteristics	Total (n = 219)	Pre-AITR (n = 108)	AITR (n = 111)	p-value
Age (mean years [SD])	28.2 (14.2)	26.9 (14.1)	29.4 (14.3)	0.202
Male sex (%)	195 (89%)	100 (92.6%)	95 (85.8%)	0.097
Mechanism
• Motor Vehicle Collision (%)	192 (87.7%)	95 (88%)	97 (87.4%)	0.893
• Fall (%)	22 (10%)	10 (9.2%)	12 (10.8%)	0.694
• Assault (%)	5 (2.3%)	3 (2.8%)	2 (1.8%)	0.622
Trauma team activation (%)	84 (38.4%)	51 (47.2%)	33 (29.7%)	0.007*
Blood transfusion in ED (%)	27 (12.3%)	18 (16.7%)	9 (8.1%)	0.054
Respiratory rate (mean breath/min [SD])	21.1 (8.2)	21.4 (8.2)	20.8 (8.2)	0.603
Heart rate (mean beat/min [SD])	102.7 (25.7)	108.7 (25.2)	96.9 (24.9)	0.001*
Systolic blood pressure (mean mm Hg [SD])	125.7 (25.3)	125.9 (28.1)	125.5 (22.2)	0.906
Glasgow Coma Scale (median [IQR])	7 (5–7)	7 (5–7)	7 (4–7)	0.447
International normalized ratio (mean [SD])	1.2 (0.3)	1.2 (0.3)	1.1 (0.2)	0.004*
Base excess (mean [SD])	-3.4 (4.1)	-3.6 (4.3)	-3.2 (3.8)	0.542
PH (mean [SD])	7.32 (0.1)	7.33 (0.1)	7.31 (0.1)	0.204
AIS-head (mean [SD])	3.08 (0.76)	3.05 (0.75)	3.13 (0.76)	0.437
Injury severity score (ISS)				0.002*
1–15 (%)	81(37%)	50 (46.3%)	31 (28.0%)	0.005*
16–25 (%)	93 (42.5%)	42 (38.9%)	51 (45.9%)	0.296
> 25 (%)	45 (20.5%)	16 (14.8%)	29 (26.1%)	0.039*
Length of ICU stay (mean days [SD])	18 (10.2)	19.2 (10.8)	16.9 (9.4)	0.086
Length of hospital stay (mean days [SD])	45.5 (27.8)	52.4 (30.4)	38.7 (23.1)	< 0.001* (95% CI 6.6–20.9)
Discharge destination
Home (%)	150 (68.5%)	63 (58.3%)	87 (78.4%)	0.001*
Rehab Center (%)	69 (31.5%)	45 (41.7%)	24 (21.6%)	0.001*

*Statistically significant at 5% level.

In the pre-intervention period, there were 63 (58.3%) patients discharged to home, compared to 87 (78.4%) after the intervention (p = 0.001; chi-squared 10.2). Time to discharge from hospital pre-intervention was 52.4 (SD 30.4) days, which improved to 38.7 (SD 23.1) days after the introduction of the new AITR program (p < 0.001; 95% CI 6.6–20.9) (Table 2).

The comparison of length of hospital stay between pre-AITR and AITR is presented in the violin plot (Fig 3).

Fig 3

Comparison of length of hospital stay between pre-AITR and AITR.

Discussion

We compared two similar groups (head injury) and an almost equal number of patients with two different rehabilitation strategies—AITR vs. non-intensive or minimal in-hospital rehabilitation (pre-AITR)—in two different periods (pre-AITR: Aug 2017–Nov 2018; AITR: Dec 2018–Dec 2019). This study demonstrated that integrating an intensive rehabilitation program with acute trauma care was associated with a significantly higher proportion of patients being discharged home and after a shorter length of stay in the hospital. As a result, the waiting list of rehabilitation candidates and the load on the only rehabilitation center in Riyadh, KFMC, are decreased.

In our cohort, the heart rate (108.7 bpm vs. 96.9 bpm; p = 0.001) at presentation to ED was significantly higher in the pre-AITR than AITR group. As the systolic blood pressure did not change in both groups (125.9 mm Hg vs. 125.5 mm Hg; p = 0.906), the difference in shock status was not significant. Moreover, the weak difference of blood transfusion requirement (16.7% vs. 8.1%; p = 0.054) in ED supports against significant difference in shock status between the two groups. The international normalized ratio (1.2 vs. 1.1; p = 0.004) was significantly higher in the pre-AITR group. Higher blood transfusion requirements in this group should have corrected the coagulopathy. Moreover, trauma system development in Saudi Arabia is recent, and defects in pre-hospital patient transfer could contribute to the difference in both groups. However, as these parameters are corrected with resuscitation measures immediately in our ED, these should not directly affect the selection of patients or outcomes in both groups.

The TTA rate in the pre-AITR cohort was significantly higher (47.2% vs. 29.7%; p = 0.007). However, ISS was comparatively lower (p = 0.002) in the pre-AITR group, which seems inconsistent as more severe injuries should get more activation. Although TTA is based on specific criteria, it is subjective (at emergency physician discretion) and may have information bias due to over- or under-triage and should not affect outcomes directly.

In our study, ISS in the AITR group was significantly higher (p = 0.002). However, the AIS-head did not show a statistically significant difference (p = 0.437) between the groups, which means we dealt with similar groups of head-injury patients in both rehab strategies. With comparable AIS, the higher ISS in the AITR group indicates more polytrauma [14-16]. On the other hand, with more polytrauma, the AITR group had a significantly lower length of hospital stay (38.7 days vs. 52.4 days; p < 0.001), which favored the success of the AITR program.

Rehabilitation service is an essential pillar of the trauma system and plays a vital role in trauma patients’ outcomes. In our situation, it is a challenge to transfer a trauma patient to a rehabilitation center due to a long waiting list. Delay in transfer causes increases in the length of hospital stay and cost. Long waits for rehabilitation have a negative impact on the functional and cognitive recovery of severely injured patients [17].

Identifying factors that contribute to the prediction of discharge disposition is crucial for efficient resource utilization and reducing cost. Several factors may influence discharge location after hospitalization [18]. Functional status due to early and advanced professional rehabilitation can affect the discharge destination. Nursing home management for all ages has demonstrated a significantly lower quality of life across multiple domains as compared with those living elsewhere [19, 20]. Return to living at home is an important patient-reported outcome following a traumatic injury. Receiving specialized acute rehabilitation is a significant and robust predictor of return to home. Specialized acute intensive rehabilitation helps patients with severe trauma maximize function and independence and return to home. Improving access to specialized acute intensive rehabilitation could potentially reduce discharges to nursing homes or other non-home destinations [21].

The introduction of a multidisciplinary AITR program was a challenge at KSMC. Bringing various allied health-care services under one umbrella was a difficult administrative decision. The PM&R department is understaffed; a dedicated ward with all relevant resources such as a gymnasium is not available to date.

This study is limited to being a retrospective cohort and only a moderate sample of patients. However, it includes consecutive patients during 29 months from the most active trauma center in the country. With only 111 cases of AITR, we attempted to develop a model to improve the trauma patient’s outcomes. The study did not analyze in depth the cognitive and functional recovery, bladder and bowel control, etc. An analysis of the Functional Independence Measure (FIM) and the Neurobehavioral Cognitive Status Examination (NCSE) in both groups would have given more strength to the study. A national trauma registry with a systematic collection of data on patient outcomes would be invaluable to assess such a program.

Conclusions

The implementation and early integration of AITR significantly reduced the percentage of patients referred to another rehabilitation or long-term facility. It also reduced the length of stay in the hospital. Continuation and expansion of the program to other trauma services with ongoing surveillance are indicated. We also emphasize the importance of PM&R specialists as the coordinators of structured, comprehensive, and holistic rehabilitation programs delivered by the multi-professional team, working in an interdisciplinary way [22]. The leadership and coordination of a PM&R physician are likely to be effective, especially for those with severe disabilities after brain injury.

Dataset.

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30 Jun 2021

PONE-D-21-13676

Does access to acute intensive trauma rehabilitation (AITR) programs affect the disposition of brain injury patients?

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Reviewer #1: Chowdhury and Leenen present the need for early rehabilitation services in the severe traumatic brain injury (TBI) setting and describe the implementation of an acute intensive trauma rehabilitation (AITR) centre in Saudi Arabia at King Saud Medical Centre (KSMC). The AITR addresses understaffing issues and patient waiting times for rehabilitation centre transfer.

The authors present retrospective data before (n=108) and after (n=111) implementation of the AITR. With the introduction of the AITR service, they report a statistically significant increase (p=0.001) in TBI patients discharged home and a reduction in time to discharge from hospital (p=0.0002).

Comments:

1) It is useful to discuss if the discharge home assessment criteria remain the same pre- and post-AITR. How much of the reduced hospital stay is due to earlier, altered, or more proactive assessment versus an improved patient recovery trajectory? I understand such a fine demarcation likely cannot be made in the context of this study, but minimally, it is useful for the reader to understand what has changed or remained static as far as criteria or periodicity of assessment for discharge home.

2) Please discuss the other significant associations on Table 2. In particular, the heart rate and blood transfusion rates both falling in the AITR setting. Is this a product of the selection criteria for the AITR? For instance, the selection criteria around oxygen saturation or stable cardiac rhythm. Is the fall in heart rate in the AITR setting, in part, to do with patient mental wellbeing, or can this be explained by better oxygen saturation in the patients passing the enrolment criteria?

3) Figure 2 needs axes descriptions. Also, the box and whisker plot isn’t very useful at informing the reader around the age distribution demographics, particularly with this distribution skewed in age and gender. Please separate the data by gender and consider a graphic which better presents the distribution, such as a violin or bean plot, or combining the box plot with a beeswarm plot.

Likewise, consider similar graphics presentations for Figure 3.

Reviewer #2: This paper presents a comparison of TBI patient outcomes (specifically, discharge destination and time to discharge) from acute care from before and after implementation of an acute inpatient trauma rehabilitation program. This is an important topic, and this study can support implementation of similar comprehensive inpatient rehabilitation programs in other similar hospital settings. Overall, the paper flows well, with some clarification required (as detailed in comments below).

Abstract

- Line 43: I recommend stating that integration of AITR reduced the percentage of patients referred to another facility (which is what was measured), rather than reducing the need to refer (which is not quite the same). (same for Line 271 under Conclusions in the Discussion)

Introduction

- Lines 72 and 80: consider more neutral language than “suffer from”, such as “experience”, which doesn’t assume a person’s subjective experience the way “suffer from” does.

- Lines 94-97 could be condensed to a single sentence indicating that with only one PM&R registrar, the focus of services was on outpatient care.

- Line 98 ends abruptly (for a long?)

Methods

- Line 131: “assess needs and select candidates for” would be better.

- What do you mean by “assessment is based on a favorable outcome” (line 134)? What specific outcome measures indicate improvement?

- Line 137-138: Does this mean no one receives outpatient therapy outside of a long-term facility?

- What resources are required for the AITR (beyond what was already provided without it)?

- Patient selection criteria #2: what do you mean by “meet the criteria of at least two of the three major therapy areas”? Does this mean that the patient requires at least 2 of 3 or that each of these areas has its own criteria that must be met for a patient to receive their services?

- Line 147-148: I don’t understand what you mean by patients who were discharged from the hospital after completion of treatment being excluded – as written, wouldn’t that be all patients?

- For the primary outcome variable for discharge destination, what were the levels of the variable? (e.g., home, long-term care facility, etc.?)

Results

- What does it mean to become a chronic TBI patient?

- What is “the rehabilitation center” referred to on line 180?

- What would trigger trauma team activation? Since this was more common pre AITR, it is important to note if the need for this intervention indicates differences in the two cohorts that could affect outcomes.

- ISS indicates that the AITR cohort had much more severe polytrauma than the pre-AITR cohort (which was not due to head injury, since AIS were equivalent), yet the pre-AITR cohort had a much higher percentage of trauma team activation (which seems inconsistent?). If the AITR cohort really had more severe polytrauma and still had better outcomes, that is a particularly important point to note. The authors note this briefly in the Discussion (lines 223-225), but don’t expand on the implications or meaning of this.

- Figures are very helpful and clear.

Discussion

- Line 222: be more specific about what you mean by “took off the pressure from”

- Lines 223-240: see comment above about ISS. The points made here about how ISS might affect ICU stay are important, but not really getting at the importance of the ISS difference in this study. More directly stating that, with comparable AIS, the higher ISS in the AITR group indicates more polytrauma, then giving more attention to how this “favors the AITR program’s success” would better highlight the study results.

- The sentence from lines 260-262 is confusing, but seems to make an important point – consider editing for clarity.

**********

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11 Jul 2021

July 11, 2021

Dear Editor,

We want to express our sincere gratitude to the reviewers for their time and effort in reviewing our manuscript. We feel that the comments and recommendations made by the expert reviewers have helped us improve our paper’s quality. Please see our detailed responses to the comments (marked as [reply]) below. Please also refer to the highlighted sentences in yellow for changes that have been made in the manuscript.

Reviewer #1:

Chowdhury and Leenen present the need for early rehabilitation services in the severe traumatic brain injury (TBI) setting and describe the implementation of an acute intensive trauma rehabilitation (AITR) centre in Saudi Arabia at King Saud Medical Centre (KSMC). The AITR addresses understaffing issues and patient waiting times for rehabilitation centre transfer.

The authors present retrospective data before (n=108) and after (n=111) implementation of the AITR. With the introduction of the AITR service, they report a statistically significant increase (p=0.001) in TBI patients discharged home and a reduction in time to discharge from hospital (p=0.0002).

1) 1st part: It is useful to discuss if the discharge home assessment criteria remain the same pre- and post-AITR.

[reply] The patients were discharged home when they achieved independence in daily activities. The criteria remained the same in the pre-AITR and AITR era. We rephrased the sentence in the ‘assessment and selection of TBI patients for AITR’ section under ‘materials and methods’ for better clarity as below (page 6, lines 109-112).

After AITR, if a patient is improved with the achievement of independence in daily activities, they are discharged home with outpatient follow-up at our PM&R department as needed. If the patient needs further rehabilitation to achieve the goals, they are transferred to a long-term rehabilitation facility.

We also added the following discharge home criteria (design, page 8, lines 131-134).

Before discharge home, a patient had to be able to: (1) execute self-care activities such as feeding, grooming, dressing, and toileting; (2) move from bed to chair/wheelchair/shower chair independently; (3) securely handle household appliances; and (4) walk with or without support inside the ward. These criteria remained the same in pre-AITR and AITR era.

1)2nd part: How much of the reduced hospital stay is due to earlier, altered, or more proactive assessment versus an improved patient recovery trajectory? I understand such a fine demarcation likely cannot be made in the context of this study, but minimally, it is useful for the reader to understand what has changed or remained static as far as criteria or periodicity of assessment for discharge home.

[reply] The patient who had a rapid and good recovery that did not require rehabilitation were excluded from the study (design; page 7, line 127-128).

Moreover, the functional recovery was measured by the Functional Independence Measure (FIM) score and available in the patient file. Our study was based on the trauma registry, which does not capture this variable. We want to thank the reviewer as he correctly mentioned to add such fine demarcation likely cannot be made in the context of this study. We will need further IRB approval and further reviews of the patients’ files to add this analysis. We briefly discussed this point in the Discussion as to the limitation of the study (page 15 and lines 259-261).

An analysis of the Functional Independence Measure (FIM) and the Neurobehavioral Cognitive Status Examination (NCSE) in both groups would have given more strength to the study.

2) Please discuss the other significant associations on Table 2. In particular, the heart rate and blood transfusion rates both falling in the AITR setting. Is this a product of the selection criteria for the AITR? For instance, the selection criteria around oxygen saturation or stable cardiac rhythm. Is the fall in heart rate in the AITR setting, in part, to do with patient mental wellbeing, or can this be explained by better oxygen saturation in the patients passing the enrolment criteria?

[reply] Table 2 data are baseline data of patients at first presentation to the emergency department and are corrected with resuscitation measures immediately. So, these variables do not affect the selection of patients. We have added the following paragraph in Discussion (page 13, lines 213-223)

In our cohort, the heart rate (108.7 bpm vs. 96.9 bpm; p = 0.001) at presentation to ED was significantly higher in the pre-AITR than AITR group. As the systolic blood pressure did not change in both groups (125.9 mm Hg vs. 125.5 mm Hg; p = 0.906), the difference in shock status was not significant. Moreover, the weak difference of blood transfusion requirement (16.7% vs. 8.1%; p = 0.054) in ED supports against significant difference in shock status between the two groups. The international normalized ratio (1.2 vs. 1.1; p = 0.004) was significantly higher in the pre-AITR group. Higher blood transfusion requirements in this group should have corrected the coagulopathy. Moreover, trauma system development in Saudi Arabia is recent, and defects in pre-hospital patient transfer could contribute to the difference in both groups. However, as these parameters are corrected with resuscitation measures immediately in our ED, these should not directly affect the selection of patients or outcomes in both groups.

3) Figure 2 needs axes descriptions. Also, the box and whisker plot isn’t very useful at informing the reader around the age distribution demographics, particularly with this distribution skewed in age and gender. Please separate the data by gender and consider a graphic which better presents the distribution, such as a violin or bean plot, or combining the box plot with a beeswarm plot.

Likewise, consider similar graphics presentations for Figure 3.

[reply] Figure 2 and Figure 3 are now updated to violin plot.

Reviewer #2:

This paper presents a comparison of TBI patient outcomes (specifically, discharge destination and time to discharge) from acute care from before and after implementation of an acute inpatient trauma rehabilitation program. This is an important topic, and this study can support implementation of similar comprehensive inpatient rehabilitation programs in other similar hospital settings. Overall, the paper flows well, with some clarification required (as detailed in comments below).

Abstract

- Line 43: I recommend stating that integration of AITR reduced the percentage of patients referred to another facility (which is what was measured), rather than reducing the need to refer (which is not quite the same). (same for Line 271 under Conclusions in the Discussion)

[reply] Corrected in both places (page 2, line 34; and page 15, lines 265-266).

Introduction

- Lines 72 and 80: consider more neutral language than “suffer from”, such as “experience”, which doesn’t assume a person’s subjective experience the way “suffer from” does.

[reply] Corrected in both places (page 3, lines 45 and 54).

- Lines 94-97 could be condensed to a single sentence indicating that with only one PM&R registrar, the focus of services was on outpatient care.

[reply] Done (page 4, line 68).

- Line 98 ends abruptly (for a long?)

[reply] Rephrased (page 4, line 70-71).

Methods

- Line 131: “assess needs and select candidates for” would be better.

[reply] Corrected (page 6, line 109).

- What do you mean by “assessment is based on a favorable outcome” (line 134)? What specific outcome measures indicate improvement?

[reply] We added “regarding achievement of independence in daily activities” for clarity (page 6, line 114-115).

A Functional Independence Measure (FIM) and the Neurobehavioral Cognitive Status Examination (NCSE) at selection and after intervention would indicate improvement. These are available in the patient file. Our study is based on the trauma registry, which does not capture this variable. The first reviewer also mentioned this point and stated that such a fine distinction likely could not be made in the context of this study. We will need further IRB approval and further reviews of the patients’ files to add this analysis. We briefly discussed this point in the Discussion as to the limitation of the study (page 15, lines 259-261).

An analysis of the Functional Independence Measure (FIM) and the Neurobehavioral Cognitive Status Examination (NCSE) in both groups would have given more strength to the study.

- Line 137-138: Does this mean no one receives outpatient therapy outside of a long-term facility?

[reply] The patients who were discharged home from our facility, our PM&R department followed them in our OPD. Further outpatient therapy as needed were decided by our PM&R team at OPD. But those patients that were transferred to a long-term facility, they were followed up by that respective facility? They do not present to our OPD. For better clarity we rephrased the sentences as below (page 6, lines 116-120).

After AITR, if a patient is improved with the achievement of independence in daily activities, they are discharged home with outpatient follow-up at our PM&R department as needed. If the patient needs further rehabilitation to achieve the goals, they are transferred to a long-term rehabilitation facility.

- What resources are required for the AITR (beyond what was already provided without it)?

[reply] We added the following paragraph to explain AITR better (page 5, lines 100-105).

The AITR program was created with specific clinical goals. The multidisciplinary team’s training was designed to help people regain function, acquire activities of daily living (ADL) independence, and reintegrate into their homes and communities. The program included physical and sensory-motor training from physiotherapy, functional re-training such as self-care and instrumental ADL from occupational therapy, and psycho-social re-training including social skills from speech therapy.

- Patient selection criteria #2: what do you mean by “meet the criteria of at least two of the three major therapy areas”? Does this mean that the patient requires at least 2 of 3 or that each of these areas has its own criteria that must be met for a patient to receive their services?

[reply] It means that the patients require at least 2 of 3 major therapy. We rephrased the sentence in the Table 1 for better clarity (page 7).

The patient must meet the criteria of at least two of the three (physiotherapy, occupational therapy, and speech-language therapy) major therapy areas.

- Line 147-148: I don’t understand what you mean by patients who were discharged from the hospital after completion of treatment being excluded – as written, wouldn’t that be all patients?

[reply] We rephrased the sentence for better clarity (page 7, lines 126-128).

The TBI patients who died in the hospital, transferred to another hospital during acute care, or were discharged from the hospital after rapid and good recovery that did not require rehabilitation and remained persistent vegetative were excluded.

- For the primary outcome variable for discharge destination, what were the levels of the variable? (e.g., home, long-term care facility, etc.?)

[reply] For clarity we rephrased in the ‘assessment and selection of TBI patients for AITR’ section (page 6 lines 116-120) as below.

After AITR, if the patient is improved with the achievement of independence in daily activities, they are discharged home with outpatient follow-up at our PM&R department as needed. If the patient needs further rehabilitation to achieve the goal, they are transferred to a long-term rehabilitation facility.

We also added the criteria for discharge home for both groups (page 8, lines 131-134).

Before discharge home, a patient had to be able to: (1) execute self-care activities such as feeding, grooming, dressing, and toileting; (2) move from bed to chair/wheelchair/shower chair independently; (3) securely handle household appliances; and (4) walk with or without support inside the ward. These criteria remained the same in pre-AITR and AITR era.

Results

- What does it mean to become a chronic TBI patient?

[reply] Chronic TBI means the patients who require rehabilitation and the patients who are persistent vegetative. Now it is clarified (page 9, lines 165-175) as below.

During the pre-AITR period, 2,021 (59.1%) patients sustained TBI, of which 118 (5.8%) died, 1,737 (86%) were discharged after rapid and good recovery that did not require rehabilitation, and 166 (8.2%) became chronic TBI patients (who required rehabilitation care or were persistent vegetative patients). Among the chronic TBI patients, 108 (65%) were selected for the rehabilitation care, and the remaining persistent vegetative patients were selected for nursing care. On the other hand, during the AITR era, 1,578 (62.8%) patients sustained TBI, of which 105 (6.7%) died, 1,315 (83.3%) were discharged after rapid and good recovery that did not require rehabilitation, and 158 (10%) became chronic TBI patients. Among the chronic TBI patients, 111 (70.3%) were selected for AITR, and the remaining persistent vegetative patients were selected for nursing care (Fig 1).

- What is “the rehabilitation center” referred to on line 180?

[reply] Here “rehabilitation center” referred to the only rehabilitation center the King Fahad Medical City in Riyadh. We replaced the word with ‘care’ (page 9 line 169).

- What would trigger trauma team activation? Since this was more common pre-AITR, it is important to note if the need for this intervention indicates differences in the two cohorts that could affect outcomes.

[reply] We added an explanation in Discussion (page 13, lines 224-228) as below.

The TTA rate in the pre-AITR cohort was significantly higher (47.2% vs. 29.7%; p = 0.007). However, ISS was comparatively lower (p = 0.002) in the pre-AITR group, which seems inconsistent as more severe injuries should get more activation. Although TTA is based on specific criteria, it is subjective (at emergency physician discretion) and may have information bias due to over- or under-triage and should not affect outcomes directly.

- ISS indicates that the AITR cohort had much more severe polytrauma than the pre-AITR cohort (which was not due to head injury, since AIS were equivalent), yet the pre-AITR cohort had a much higher percentage of trauma team activation (which seems inconsistent?). If the AITR cohort really had more severe polytrauma and still had better outcomes, that is a particularly important point to note. The authors note this briefly in the Discussion (lines 223-225), but don’t expand on the implications or meaning of this.

[reply] Trauma team activation is not a reliable (subjective) variable due to under-or over-triage in terms of patient outcomes, as we stated above. AIS and ISS are reliable as it is based on actual anatomical injury supported by radiological investigations such as pan CT scan. Moreover, all our trauma registry data collectors are AAAM certified and qualified to do so. We rephrased the sentences for clarity in Discussion ass below (page 13-14; lines 231-234).

With comparable AIS, the higher ISS in the AITR group indicates more polytrauma [14, 15]. On the other hand, with more polytrauma, the AITR group had a significantly lower length of hospital stay (38.7 days vs. 52.4 days; p < 0.001), which favored the success of the AITR program.

- Figures are very helpful and clear.

[reply] Thanks so much. We have updated figures 2 and 3 to the violin plot as per the recommendation of the first reviewer.

Discussion

- Line 222: be more specific about what you mean by “took off the pressure from”

[reply] We meant after the introduction of AITR at our hospital more patient is going home instead of waiting to go to a rehabilitation center. So, it decreased the load on the rehabilitation center. We rephrased the sentence as below (Page 13, lines 210-212).

As a result, the waiting list of rehabilitation candidates and the load on the only rehabilitation center in Riyadh, KFMC, are decreased.

- Lines 223-240: see comment above about ISS. The points made here about how ISS might affect ICU stay are important, but not really getting at the importance of the ISS difference in this study. More directly stating that, with comparable AIS, the higher ISS in the AITR group indicates more polytrauma, then giving more attention to how this “favors the AITR program’s success” would better highlight the study results.

[reply] Thanks so much for pointing out this. We deleted the lines 225-239 and added the following sentences (page 13-14; lines 231-234).

With comparable AIS, the higher ISS in the AITR group indicates more polytrauma [14, 15]. On the other hand, with more polytrauma, the AITR group had a significantly lower length of hospital stay (38.7 days vs. 52.4 days; p < 0.001), which favored the success of the AITR program.

- The sentence from lines 260-262 is confusing, but seems to make an important point – consider editing for clarity.

[reply] We have deleted the sentences.

Response to additional editorial comment:

When submitting your revision, we need you to address these additional requirements.

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[reply] We updated the revised manuscript accordingly.

2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[reply] The references are now updated as per journal requirements and the reference number 2 is replaced with a new reference:

Stocchetti N, Zanier ER. Chronic impact of traumatic brain injury on outcome and quality of life: a narrative review. Crit Care. 2016 Jun 21;20(1):148. doi: 10.1186/s13054-016-1318-1. PMID: 27323708; PMCID: PMC4915181.

3. Thank you for including your ethics statement:

“The study was approved by KSMC institutional review board with a reference number of H1RI- 03-Oct18-02. The IRB committee approved a waiver of the requirement to seek informed consent from the participants for a retrospective review of their data.”.

Please amend your current ethics statement to include the full name of the ethics committee/institutional review board(s) that approved your specific study.

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[reply] KSMC is elaborated to King Saud Medical City.

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[reply] It is corrected accordingly, and the statement is added in the cover letter.

5. Please amend your authorship list in your manuscript file to include author andi asrifine

[reply] resolved.

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[reply] It is corrected accordingly (page 9, lines 156-160) and the statement is added in the cover letter.

On behalf of all authors,

Yours sincerely,

Dr. Sharfuddin Chowdhury

Submitted filename: Author Response.docx

Click here for additional data file.

4 Aug 2021

Does access to acute intensive trauma rehabilitation (AITR) programs affect the disposition of brain injury patients?

PONE-D-21-13676R1

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Reviewer #1: All comments have been addressed

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6 Aug 2021

PONE-D-21-13676R1

Does access to acute intensive trauma rehabilitation (AITR) programs affect the disposition of brain injury patients?

Dear Dr. Chowdhury:

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